Search results with tag "Improving documentation"
Strategies for Improving Documentation - HIROC
www.hiroc.comStrategies for Improving Documentation: Lessons from Medical-Legal Claims Documentation should accurately reflect the needs of the patient, the . treatments and interventions provided, and the patient’s outcomes. Anyone reading the record should clearly be able to determine: 1.
AN ESSENTIAL GUIDE TO CLINICAL DOCUMENTATION …
www.echima.caimproving documentation. The CDI Specialist A key aspect of the CDI program is to review documentation in a chart from a clinical perspective, keeping in mind disease processes, symptomology, and appropriate treatment. Physician documentation is often noted in clinical terminology, not always listing the diagnostic equivalent.
Improving Your Documentation: Now More Than Ever, …
www.lota.orgImproving Documentation Responsibility Guidelines Skill Purpose Quality Accountability Responsibility You, as a therapist, have a professional responsibility to explain what has beendone, what will be done, and why itwas done in clear, unambiguous terms that will be understandable to